Washington Practitioner Application 150 July 2013Page 1 of 13PRACTITIO - PDF document

1 n n Washington Practitioner Application
n n Washington Practitioner Application – July 2013Page 1 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationWashington Practitioner Application To use the Washington Practitioner Application (WPA), follow these instructions: Keep an unsigned and undated copy of the application on file for future requests. When a request is received, send a copy of the completed application, making sure that all information is 1. INSTRUCTIONS This form should be typed or legibly printed in black or blue ink. If more space is needed than provided on original, attach additional sheets and reference the question being answered. Please do not use abbreviationsCurrent copies of the following documents must be submitted with this application: State Professional License(s) DEA Certificate ECFMG (if applicable) Face Sheet of Professional Liability Policy or Certificate Curriculum Vitae (Not an acceptable substitute for completing the application.) ** All sections must be completed in their entirety. ** Last Name: (include suffix; Jr., Sr., III) First: Middle: Degree(s): List any other name(s) under which you have been known by reference, licensing and or educational institutions: Home Mailing Address: State: Zip Code: Home Telephone Number: ( ) Pager Number: ( ) Cell Phone Number: ( ) E-Mail Address: Birth Date: (mm/dd/yyyy) Birth Place (cit Social Security Number: Male Female Languages Fluently Spoken by Practitioner: Have you ever voluntarily opted-out of Medicare? Yes No Medicare Number: (WA) Medicaid (DSHS) Number(s): Specialty primarily practicing: Sub specialties primarily practicing: Washington Practitioner Application – July 2013Page 2 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationOther Professional Interests in Practice, Research, etc.: 3. PRACTICE INFORMATION

2 CHECK ALL THAT APPLY E
CHECK ALL THAT APPLY Effective Date at Primary Practice location (MM/YY) __________ Practice Setting Clinic/Group Solo Practice Home Based Hospital Based Primary Care Site Urgent Care Other Practitioner Profile PCP Specialist Check if you are both PCP & OB OB in your practice Yes No Deliveries Yes No Name of Practice / Affiliation or Clinic Name: Department Name (if hospital based): Primary Office Street Address: City: State: Zip Code: Org. NPI#: Patient Appointment Telephone Number: ( ) Fax Number: ( ) Mailing Address: (if different from above) Billing Address: (if different from above) Practice Website Office Manager / Administrator Name: Administration Telephone Number: ( ) E-mail Address: Fax Number: ( ) Credentialing Contact (if different from above): Telephone Number: ( ) E-mail Address: Fax Number: ( ) mber: Federal Tax ID Number: Is the office wheelchair accessible? Yes No Office Hours Are you accepting new patients? Yes No Have you limited your practice in any way (e.g. 18 years or older?) Yes No If yes, please explain: __________________________________________________________________________________________________________________ Do you currently supervise ARNP’s or PA’s? Yes No If yes, please provide the name and specialty below: __________________________________________________________________________________________________________________ Please list languages fluently spoken by office staff: __________________________________________________________________________________________________________________ Monday: ________________________ Tuesday: ________________________ Wednesday: ______________________ Thursday: ________________________ Friday: __________________________ Saturday: ________________________ Sunday:__________________________ Do you provide 24 hour coverage? Yes No If no, please explain how your pati

3 ents obtain advice and care after hours:
ents obtain advice and care after hours: __________________________________________________________________________________ A. Inpatient Coverage Plan (for those without admitting privileges) Does Not Apply Name of Admitting Physician/Practice/Clinic/Group: Hospital Where privileged: B. Covering Practitioners/Call Group Does Not Apply Provider Name, Degree Specialty Address Phone Number Washington Practitioner Application – July 2013Page 3 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application Attach a list of additional covering practitioners if needed Effective Date at Secondary Practice location (MM/YY) __________ CHECK ALL THAT APPLY Practice Setting Clinic/Group Solo Practice Home Based Hospital Based Primary Care Site Urgent Care Other Practitioner Profile PCP Specialist Check if you are both PCP & OB OB in your practice Yes No Deliveries Yes No Name of Secondary Practice / Affiliation or Clinic Name: Department Name (if hospital based): Primary Office Street Address: City: State: Zip Code: Org. NPI# Patient Appointment Telephone Number: ( ) Fax Number: ( ) Mailing Address: (if different from above) Billing Address: (if different from above) Practice Website Office Manager / Administrator Name: Administration Telephone Number: ( ) E-mail Address: Fax Number: ( ) Credentialing Contact (if different from above): Telephone Number: ( ) E-mail Address: Fax Number: ( ) mber: Federal Tax ID Number: Is the office wheelchair accessible? Yes No Office Are you accepting new patients? Yes No Have you limited your practice in any way (e.g. 18 years or older?) Yes No If yes, please explain: __________________________________________________________________________________________________________________ Do you currently sup

4 ervise ARNP’s or PA’s? Yes
ervise ARNP’s or PA’s? Yes No If yes, please provide the name and specialty below: __________________________________________________________________________________________________________________ Please list languages fluently spoken by office staff: __________________________________________________________________________________________________________________ Monday: ________________________ Tuesday: ________________________ Wednesday: ______________________ Thursday: ________________________ Friday: __________________________ Saturday: ________________________ Sunday:__________________________ Do you provide 24 hour coverage? Yes No If no, please explain how your patients obtain advice and care after hours: __________________________________________________________________________________ _ ________________________________________ A. Inpatient Coverage Plan (for those without admitting privileges) Does Not Apply Name of Admitting Physician/Practice/Clinic/Group: Hospital Where privileged: B. Covering Practitioners/Call Group Does Not Apply Provider Name, Degree Specialty Address Phone Number Washington Practitioner Application – July 2013Page 4 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application Attach a list of additional covering practitioners if needed LIST OTHER OFFICE LOCATIONS WITH THE ABOVE INFORMATION ON A SEPARATE SHEET 4. PROFESSIONAL LICENSURE, D CERTIFICATIONS(Attach Additional Sheet if Necessary) Washington State Professional License/Registration/Cert Number: Issue Date: Expiration Date Name of Sponsor if required by licensure, (e.g. Physician’s Assistant). Drug Enforcement Administration (DEA) Registration Number: Expiration Date: ECFMG Number (applicable to foreign medical graduates): Date Issued: 5. ALL OTHER PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS Number: Date Issued Exp. Date Yr. RelinquishReason: Number: Date Issued Exp.

5 Date Yr. RelinquishReason: Number: Date
Date Yr. RelinquishReason: Number: Date Issued Exp. Date Yr. RelinquishReason: 6. UNDERGRADUATE EDUCATION (Do not abbreviate) Does Not Apply College or University Name: Degree Received(be specific, e.g. BS Graduation Date (mm/yyyy) Mailing Address: Zip Code: College or University Name: Degree Received(be specific, e.g. BS Graduation Date (mm/yyyy) Mailing Address: Zip Code: Do not abbreviate Medical/Professional School: (mm/yyyy) Graduation Date (mm/yyyy) Degree Received Mailing Address: Zip Code: Medical/Professional School: Start Date (mm/yyyy) Graduation Date (mm/yyyy) Degree Received Mailing Address: Zip Code: 8. MASTER DEGREE PROGRAM OR POST GRADUATE EDUCATION Does Not Apply Institution: Address City Code: Dates Attended (mm/yyyy - mm/yyyy): ( / ) - ( / ) Program or Course of Study: Faculty Director: Washington Practitioner Application – July 2013Page 5 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application9. INTERNSHIP/PGYI (Attach Additional Sheet if Necessary) Does Not Apply Phone Number: Fax Number: Program Director: Mailing Address: Zip Code: Type of Internship: Specialty: From (mm/yyyy): To (mm/yyyy): 10. RESIDENCIES (Attach Additional Sheet if Necessary) Does Not Apply Phone Number: Fax Number: Program Director: Mailing Address: Zip Code: Type of Residency: Specialty: From (mm/yyyy): To (mm/yyyy): Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.) Phone Number: Fax Number: Program Director: Mailing Address: Zip Code: Type of Residency: Specialty: From (mm/yyyy): To (mm/yyyy): Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.) 11. FELLOWSHIPS (Attach Additional Sheet if Necessary) Does Not Apply Phone Number: Fax Number: Program Director: Mailing Address: Zip Code: Course of Study: From (mm/yyyy): To (mm/yyyy):

6 Did you successfully complete the prog
Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.) Phone Number: Fax Number: Program Director: Mailing Address: Zip Code: Course of Study: From (mm/yyyy): To (mm/yyyy): Did you successfully complete the program? Yes No (If "No", please explain on separate sheet.) 12. PRECEPTORSHIP (Attach Additional Sheet if Necessary) Does Not Apply Institution: Address: City: State: Code: Telephone Number ( ) Fax Number Email Address Dates Attended (mm/yyyy - mm/yyyy): ( / ) - ( / ) Training: Department Chairman: Washington Practitioner Application – July 2013Page 6 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application13. FACULTY/TEACHING APPOINTMENTS (Attach Additional Sheet if Necessary) Does Not Apply Institution: Address: City: State: Code: Telephone Number Fax Number Email Address Dates Attended (mm/yyyy - mm/yyyy): ( / ) - ( / ) Position: Faculty Director: 14. BOARD CERTIFICATION Does Not Apply Are you board or otherwise professionally certified? If "Yes", please complete below: If "No", describe your intent for certification, if any, and dates of testing for Certification on separate sheet. Issuing Board/Entity and State Issued Specialty Expiration Date Have you applied for certification other than those indicated above? Yes No If so, list certification and date: If you participate in a specialty which does not have board certification, please indicate specialty: 15. OTHER CERTIFICATIONS ACLS, BLS, ATLS, PALS, NALS (e.g., Fluoroscopy, Radiography, etc.) (Attach Certificate if Applicable) Type: Number: Expiration Date: Type: Number: Expiration Date: 16. HOSPITAL, MILITARY, AND OTHER INSTITUTIONAL AFFILITATIONS Does Not Apply Please list in reverse chronological order (with the current affiliation(

7 s) first)you (A) Current Hospital affili
s) first)you (A) Current Hospital affiliation, (B) Previous Hospital Affiliations, (C) Current Military Affiliation, (D) Previous Militcations in process This includes hospitals, surgery centers, institutions, corporations, military assignments, or government agencies. Ifmore space is needed, attach additional sheet(s). List only affiliations here, list employment in section XVII, Work History. A. CURRENT HOSPITAL AFFILIATIONS (Do not abbreviate Name of Primary Admitting Hospital: Mailing Address Phone number: Fax Number: Status (active, provisional, courtesy, temporary, etc.): Appointment Date: Can you admit / follow clients of your primary, secondary, other practice locations? Does Not Apply Primary practice admits only Secondary Practice admits only can admit to for all locations Washington Practitioner Application – July 2013Page 7 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationName of Secondary Admitting Hospital: Department: Mailing Address Phone number: Fax Number: Status: Appointment Date: Can you admit / follow clients of your primary, secondary, other practice locations? Does Not Apply Primary practice admits only Secondary Practice admits only Can admit to for all location Name of Other Institutions: Mailing Address Phone number: Fax Number: Status: Appointment Date: Can you admit / follow clients of your primary, secondary, other practice locations? Does Not Apply Primary practice admits only Secondary Practice admits only Can admit to for all locations B….PREVIOUS HOSPITAL AFFILIATIONS (Do not abbreviate) Name of Admitting Hospital: Department: Mailing Address Previous Status (active, provisional, courtesy, temporary, etc.): From (mm/yyyy): To (mm/yyyy): Reason for Leaving: Name of Admitting Hospital: Department: Mailing Address Previous St

8 atus (active, provisional, courtesy, tem
atus (active, provisional, courtesy, temporary, etc.): From (mm/yyyy): To (mm/yyyy): Reason for Leaving: Name of Admitting Hospital: Department: Mailing Address Previous Status (active, provisional, courtesy, temporary, etc.): From (mm/yyyy): To (mm/yyyy): Reason for Leaving: C. CURRENT MILITARY AFFILIATIONS (Do not abbreviate) Please include Military Reserves Division Name of Primary Base: Mailing Address Fax Number: Washington Practitioner Application – July 2013Page 8 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationPhone number: Appointment Date: Status (active, provisional, courtesy, temporary, etc.): ATIONS (Do not abbreviate)Division Name of Primary Base: Mailing Address Fax Number: Phone number: Appointment Date: Status (active, provisional, courtesy, temporary, etc.): E. APPLICATIONS IN PROCESS (Do not abbreviate Hospital/Institution: Phone Number/Fax Number: Date Application Submitted: Mailing Address: Zip Code: Hospital/Institution: Phone Number/Fax Number: Date Application Submitted: Mailing Address: Zip Code: 17. WORK HISTORY (Do not abbreviate)(Do not list if already listed under Hospital Affiliations) Chronologically list all work history activities since completion of professional training (use extra sheets if necessary). Thinformation must be complete. A curriculum vitae is not sufficient. Name of Practice / Employer: Contact Name: Telephone Number: ( ) Reason for Leaving: Email Address Fax Number: ( ) Mailing Address City: State: Zip: From (mm/yyyy) To (mm/yyyy) Name of Practice / Employer: Contact Name: Telephone Number: ( ) Reason for Leaving: Email Address Fax Number: ( ) Mailing Address: City: State: Zip Code: From (mm/yyyy): To (mm/yyyy): Name of Practice / Employer: Contact Name: Telephone Number: ( ) Reason for Leaving: Email Address Fax Number: ( ) Mailing Address: City: State: Zip Code: From

9 (mm/yyyy): To (mm/yyyy): Washington
(mm/yyyy): To (mm/yyyy): Washington Practitioner Application – July 2013Page 9 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application18. GAPS IN HISTORY Please account for all gaps between dates of medical/professional school graduation to present not covered elsewhere within this application. Include dates, activity and names where applicable: From (mm/yyyy): To (mm/yyyy): 19. PEER REFERENCES professional references, from your specialty area, not including relatives, who have worked with you in the past two years. References must be from individuals who through recent observation, are directly familiar with your work and can attest to your clinical competence in your specialty area. If you have been out of residency or fellowship for a period ofless then three years, one reference must be from the Program Director. Allied Health Provider must provide at least one reference from the same discipline. Name of Reference: Title and Specialty: E-mail Address: Mailing Address: Zip Code: Telephone Number: ( ) Fax Number: ( ) Cell Phone Number: (Optional) ( ) Name of Reference: Title and Specialty: E-mail Address: Mailing Address: Zip Code: Telephone Number: ( ) Fax Number: ( ) Cell Phone Number: (Optional) ( ) Name of Reference: Title and Specialty: E-mail Address: Mailing Address: Zip Code: Telephone Number: ( ) Fax Number: ( ) Cell Phone Number: (Optional) ( ) 20. PROFESSIONAL AFFILIATIONS (Do not abbreviate Please List Membership In All Professional Societies Complete Name of Society: Current Member / / . YES NO / / . YES NO 21. PROFESSIONAL LIABILITY (Do not abbreviate A. Current Insurance Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Per claim amount: $ Aggregate amount: $ Date Began

10 : Expiration Date: Washington Practitio
: Expiration Date: Washington Practitioner Application – July 2013Page 10 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationB. PREVIOUS PROFESSIONAL LIABILITY CARRIERS WITHIN THE LAST TEN YEARS(Attach Additional Sheet if Necessary) Name of Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Policy Number: From (mm/yyyy): To (mm/yyyy): Name of Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Policy Number: From (mm/yyyy): To (mm/yyyy): Name of Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Policy Number: From (mm/yyyy): To (mm/yyyy): Name of Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Policy Number: From (mm/yyyy): To (mm/yyyy): Name of Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Policy Number: From (mm/yyyy): To (mm/yyyy): Name of Carrier: Policy Number: Mailing Address: Zip Code: Phone Number: Fax Number: Policy Number: From (mm/yyyy): To (mm/yyyy): Washington Practitioner Application – July 2013Page 11 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationWASHINGTON PRACTITIONER ATTESTATION QUESTIONSPlease answer all of the following questions. If your answer to any of the following questions is 'Yes", provide details as spIf you attach additional sheets, sign and date each sheet. A. PROFESSIONAL SANCTIONS 1. Have you ever been, or are you now in the process of being denied, revoked, terminated, suspended, restricted, reduced, limited, sanctioned, placed on probation, monitored, or not renewed for any of the following? Or have you voluntarily or involuntarily relinquished, withdrawn, or failed to proceed with an application for any of the following in order to avoid an adverse action or to preclude an investigation or while under investigation relating to profe

11 ssional competence or conduct? a. Lice
ssional competence or conduct? a. License to practice any profession in any jurisdiction NO b. Other professional registration or certification in any jurisdiction NO c. Specialty or subspecialty board certification NO d. Membership on any hospital medical staff NO e. Clinical privileges at any facility, including hospitals, ambulatory surgical centers, skilled nursing facilities, etc. YES NO f. Medicare, Medicaid, FDA, NIH (Office of Human Research Protection), governmental, national or international regulatory agency or any public program YES NO g. Professional society membership or fellowship NO h. Participation/membership in an HMO, PPO, IPA, PHO, Health Plan or other entity NO i. Academic Appointment YES NO j. Authority to prescribe controlled substances (DEA or other authority) NO 2. Have you ever been subject to review, challenges, and/or disciplinary action, formal or informal, by an ethics committee, licensing board, medical disciplinary board, professional association or education/training institution? YES NO 3. Have you been found by a state professional disciplinary board to have committed unprofessional conduct as defined in applicable state provisions? YES NO 4. Have you ever been the subject of any reports to a state, federal, national data bank, or state licensing or disciplinary entity? YES NO B. CRIMINAL HISTORY 1. Have you ever been charged with a criminal violation (felony or misdemeanor) resulting in either a plea bargain, conviction on the original or lesser charge, or payment of a fine, suspended sentence, community service or other obligation? YES NO a. Do you have notice of any such anticipated charges? NO b. Are you currently under governmental investigation? NO C. AFFIRMATION OF ABILITIES 1. Do you presently use any drugs illegally? NO 2. Do you have, or have you had in the last five years, any physical condition, mental health condition, or chemical dependency condition (alcohol or other substance) that aff

12 ects or will affect your current ability
ects or will affect your current ability to practice with or without reasonable accommodation? If reasonable accommodation is required, specify the accommodations required. If the answer to this question is yes, please identify and describe any rehabilitation program in which you are or were enrolled which assures your ability to adhere to prevailing standards of professional performance. YES NO 3. Are you unable to perform any of the services/clinical privileges required by the applicable participating practitioner agreement/hospital agreement, with or without reasonable accommodation, according to accepted standards of professional performance? YES NO D. LITIGATION AND MALPRACTICE COVERAGE HISTORY (If you answer "Yes" to any of the questions in this please document in Section XXI. PROFESSIONAL LIABILITY ACTION DETAIL of this application.) 1. Have allegations or claims of professional negligence been made against you at any time, whether or not you were individually named in the claim or lawsuit? YES NO 2. Have you or your insurance carrier(s) ever paid any money on your behalf to settle/resolve a professional malpractice claim (not necessarily a lawsuit) and/or to satisfy a judgement (court-ordered damage award) in a professional lawsuit? YES NO 3. Are there any such claims being asserted against you now? NO 4. Have you ever been denied professional liability coverage or has your coverage ever been terminated, not renewed, restricted, or modified (e.g. reduced limits, restricted coverage, YES NO 5. Are any of the privileges that you are requesting not covered by your current malpractice coverage? YES NO I warrant that all the statements made on this form and on any attached information sheets are complete, accurate, and current.understand that any material misstatements in, or omissions from, this statement constitute cause for denial of membership or cfor summary dismissal from the entity to which this statement has been submitted. Applicant's Signature: Date Washington Pract

13 itioner Application – July 2013Page
itioner Application – July 2013Page 12 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application 22. PROFESSIONAL LIABILITY ACTION DETAIL – CONFIDENTIAL Does Not Apply Practitioner Name:(print or type) Please list any past or current professional liability claim(s) or lawsuit(s), in which allegations of professional negligence were made against you, whether or not you were individually named in the claim or lawsuit. Please do not include patient names or other HIPAA protected PHI. Photocopy this page as needed and submit a separate page for EACH claim/event. A legible signed practitioner narrative that addresses all of the following details is an Date and clinical details of the incident, with preceding events: Date: Details: Your role and specific responsibility in the incident: Subsequent events, including patient’s clinical outcome: Date suit or claim was filed: Name and Address of Insurance Carrier that handled the claim: Your status in the legal action (primary defendant, co-defendant, other): Current status of suit or other action: Date of settlement, judgment, or dismissal: Washington Practitioner Application – July 2013Page 13 of 13PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the applicationIf case was settled out-of-court, or with a 23. ATTESTATION I certify the information in this entire application is complete, accurate, and current. I acknowledge that any misstatements or omissions from this application constitute cause for denial of membership or cause for summary dismissal from the entity to which this statement has been made. A photocopy of this application has the same force and effect as the original. I have reviewed this information as of the most recent date listed below. Here: (Stamped signature is not acceptable) Date: Review dates and initials: n n n n n n n n